Provider Demographics
NPI:1851455497
Name:PARK, YOUNG JAE (DC)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:JAE
Last Name:PARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 S WESTERN AVE RM 307
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006
Mailing Address - Country:US
Mailing Address - Phone:213-500-8432
Mailing Address - Fax:213-388-7763
Practice Address - Street 1:981 S WESTERN AVE RM 307
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006
Practice Address - Country:US
Practice Address - Phone:213-500-8432
Practice Address - Fax:213-388-7763
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26115111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC26115Medicare ID - Type Unspecified